MONTREAL - For a year, they sat in the ER of the Jewish General Hospital, watching.

Researchers from McGill University’s department of health sciences management, the observers counted patients as they arrived, by ambulance or on their own steam, inching their way past the triage nurse to wait their turn to see the doctor.

The visitors clocked nurses and watched physicians as they ordered tests. They took notes on how many beds there were and how many were occupied.

Among Montreal’s overstretched emergency wards – on any given day, the average Montreal ER runs at 117 per cent capacity – the Jewish General is known for smooth delivery of services and shorter waiting times.

That’s provided you think an average waiting time of 16 hours and 18 minutes is acceptable. (That’s one hour and 18 minutes better than the provincial norm and roughly 18 hours better that the average wait at Maisonneuve-Rosemont.)

But imagine if the ER at the Jewish, which has been tagged for a $119.8 million overhaul by the end of 2012, could be better, more efficient, and patient-friendly.

And what if those improvements could be transposed and mimicked by other hospitals, in Montreal and beyond – wherever gurneys routinely line the hallways?

“There is a consensus that something needs to be done,” says Vedat Verter, a professor of operations management at McGill University, where he’s heading up the research project that has been using the Jewish General to create a computer simulated model of a working ER.

Once their model is proven to be a reliable replica of how the Jewish General’s ER works, Verter’s team will test how it could be improved, by something as basic as having more doctors on duty during peak hours, or having different entrances for ambulance and walk-in patients.

For Verter, founding president of the College of Healthcare Operations Management and organizer of an international conference on health care being held in Montreal next June, what needs to be done is fairly straightforward.

Put the patient at the centre of the system.

Do a better job managing costs, quality and access to health care.

Find and keep more family doctors.

Those waiting times in ER matter, and not only because time is money. Waiting is one of those infuriating things everyone can understand, a simple measure of how well, or how badly, the health care system is working in a period when the cost of being sick seems to be madly skyrocketing, both for the public purse and for the patient.

This year, Quebec expects to spend $28 billion – 44.7 per cent of its global budget – on health care. Total health expenditure, Canada 2007 Predictions are that the proportion of public money going to pay health costs will continue to swell as a larger proportion of the population gets older and frailer.

But Quebecers will spend another $11 billion on health care that isn’t covered by government funds, paying for everything from private duty nurses and chiropractors to over-the-counter cough medicine.

Suddenly, it seems, we find ourselves shelling out for services that aren’t covered by the Canada Health Act – everything from newfangled technologies and home-based chemotherapy treatment, which can run to $65,000 a year, to the antipsychotics or Ritalin many can’t seem to function without.

In last spring’s budget, Finance Minister Raymond Bachand announced a health tax of up to $200 per Quebec taxpayer to help offset the spiralling cost of health care.

Threats of a user fee of $25 per doctor’s visit were dropped earlier this month, shouted down by an angry chorus of public opinion makers.

Meanwhile, the government has adopted a budget balancing measure that will slash $33.3 million from the administrative costs of local health care spending this year. David Levine, director of the Montreal Regional Health and Social Services Agency, insists the cuts, mainly to training and travel budgets, will have no impact on front-line services.

But before we start throwing more cash into the system – or taking it away – shouldn’t we have a better idea of how the money we are already pumping into the system is being spent?

For instance, can Quebec, a province forever scrambling to train enough family doctors to go around, afford to invest $80 million a year on an enhanced in-vitro fertilization program?

Major improvements in drug treatments have been a godsend for many, allowing better control of hypertension and cholesterol, cancer, mental illness and HIV/AIDS, even supplanting the need for surgery in heart patients.

But are we allowing Big Pharma to dictate how we spend our money when we throw hundreds of millions into fighting a pandemic that doesn’t pan out or when doctors prescribe daily doses of medications for illnesses that didn’t even have a name when Tommy Douglas inspired Canadians to make free access to health care a pillar of our national identity?

Is too much money being spent on bureaucrats doling out bed pans and rubber gloves and too little being spent on nurses, home visits and respite care?

Are hospitals really doing the best they can do with their budgets? Does anyone even know the answer to these questions?

“Quebec must be reaching a level where it’s got to wonder – with the proportion of its expenditure on debt and the proportion on health care, there is very little left in the middle for education and other important services,” says Wendy Thomson, director of the School of Social Work at McGill.

“Before you start introducing user fees, before you start introducing more money into the system, I really think there is just a huge obligation, a duty, for us to know what we are getting for the current money that we spend.”

A repatriated Montrealer who sits on the regional health board, Thomson played a key role in lauded reform of Britain’s National Health Service during Tony Blair’s term as prime minister.

There, she says, any new investment was clearly linked to “deliverables,” targets set for improvements in the time it would take to see a general practitioner, be treated in the ER or get a new hip.

“We thought the political deal was that if you are going to spend more money on it, you’ve got to demonstrate to the public that they are going to get something better. I wish that sense of a deal was a little stronger here in Quebec. Because we still haven’t heard what we are going to get for our health tax,” Thomson said.

“Personally, I would be willing to see money being invested in better health care and put up with more potholes,” says health care economist Erin Strumpf.

A McGill professor, Strumpf studies the cost, efficiency and impact of health policies.

“You might decide that being healthier and being alive longer … might be worth even more money. Or you could discover that the system could be organized differently for a better return and better outcomes.”

Part of the challenge, she said, is measuring the outcomes, which basically comes down to how sick a patient was going into the health care system and how well they are when they leave.

The trouble, said Strumpf, is that data on outcomes is sketchy.

“The trickier part is inside the walls of the hospital, which is where patients tend to be sickest and where the most expensive procedures are performed. It is harder to track those costs. Essentially, the hospital gets what it spent the previous year, but how it is spent is up to them.

“It’s a big black box.”

Toss the words health care into a crowded room these days and brace yourself for the explosion of stories of yawning gaps in service or insurance coverage, of dubious uses of limited resources.

A co-worker spends a week in hospital waiting for heart bypass surgery. His condition is stable but sending him home would mean surrendering his place in the surgical hierarchy.

Your father is in agony, popping painkillers while waiting for a hernia operation. He’s been told he won’t go under the knife for at least five weeks. Now he’s made up his mind to fork over the $2,500 and “go private,” assuming he can find a surgeon with a hole in his schedule.

Your 92-year-old aunt doesn’t have a family doctor. So when she gets a stomach ache, she trots down to the Montreal General, another non-emergency who will wait hours to see a physician, feeling increasingly more stressed, weary and agitated.

The hospital where you work has two gleaming CT scans side by side. Yet they stand idle for 20 hours of the day. No one seems to be able to explain why.

Nationally, health care costs now account for 11.9 per cent of Canada’s economy.

The closer you are to the cradle or the grave, the higher your health costs. Babies under the age of one cost the health care system roughly $8,239. Average annual costs then drop for the next 60-odd years, when per-person health costs gradually rise to $10,470 for people 75 to 79 and $17,469 for people 80 and older.

Canada is the third highest spender on health care among 24 members of the Organization for Economic Co-operation and Development (OECD). Yet Canada also has the third highest rate of mortality from diabetes and the second highest rate on infant mortality.

The Conference Board of Canada predicts that within the next 15 years – the time it takes for today’s young seniors to reach the ripe age of 75 – health care costs will account for 15 per cent of the county’s gross national product.

But there are other new wrinkles in the middle-aged face of universal health care, ones that are only peripherally linked to the demographics of aging.

Up until 1997, the three major costs for health care in Quebec, as elsewhere in Canada, were hospitals, doctors and drugs.

Over the last 13 years, there has been a shift in the order. Hospitals still soak up the largest share of the pie, although its proportion of health care costs has dropped sharply, from 47 per cent 30 years ago to 28 per cent of the total.

Meanwhile, drug costs have soared, overtaking physicians to become the second largest expense.

While that’s true across Canada, the Canadian Institute for Health Information reports the gap is wider in Quebec, where drug costs are higher than they are anywhere else in the country, and doctors earn less.

At the same time, individuals find themselves picking up a larger share of the tab.

No longer are out-of-pocket costs limited to visits to the dentist, physiotherapist and the eye doctor, which, by the way, account for 10.8 per cent of Canada’s total health care costs.

Five years ago, the Supreme Court of Canada’s landmark ruling in the case of Dr. Jacques Chaouilli paved the way for patients in Quebec who were fed up waiting for hip and knee surgery and other non-emergency procedures to opt out of the system – provided they are willing to pay the bill.

Premiums for private or group insurance account for 12.8 per cent of Canadians’ health expenditures.

In 2007, a study by the Organization for Economic Cooperation and Development said Canada ranked third, behind the U.S. and Switzerland, when it came to private sector spending on health, which included both insurance and private payments.

Though we still end up paying through our taxes, at least Quebec’s mandatory drug insurance plan helps cushion individuals from the blow of paying the full cost of prescription drugs, which have climbed from 10 to 17 per cent of the health care budget since 1985. Quebec’s drug plan puts the annual cost of Aromasin, used to treat breast cancer, at $1,825, while Tarceva, approved for home use by patients with lung cancer, costs $19,465 a year.

Claude Lemay, manager of CIHI’s Quebec office, sees a couple of explanations why drugs cost more in Quebec than they do in the rest of the country. Extended licensing protection for brand names was one of the carrots Quebec used to attract pharmaceutical companies to set up business here and the province may still see the pros of jobs and investment outweighing the cons of higher drug costs. And because everyone in the province is covered by a public or private drug plan, there may be less pressure for physicians to prescribe a less expensive medication that would be just as effective.

Quebecers have it relatively easy compared with residents of New Brunswick and Prince Edward Island, where checkerboard insurance coverage leaves many seasonal and self-employed workers without a safety net when illness strikes.

“What we are seeing is an evolution of health care coverage by postal code,” says Aaron Levo, assistant director of national public issues for the Canadian Cancer Society, which is pushing hard for a national policy protecting those who need a “catastrophic drug plan” covering sophisticated cancer treatments administered at home that can cost as much as $74,500 a year. “New drug therapies have exposed gaps and disparities in coverage depending where you live and how much money you make.”

Yet even in Quebec, a cancer patient undergoing a chemotherapy protocol at home or a senior with multiple prescriptions for chronic diseases can easily expect to spend up to $954 of their own money before reaching the annual spending cap.

For people at the bottom of the economic heap, paying even a fraction of the cost of medication and other treatments could be too much, prodding them to skimp or cut their prescriptions.

Robyn Tamblyn, a professor of epidemiology and biostatistics at McGill, published a study detailing the negative impact of drug cost-sharing schemes on the poor and the elderly.

“Cost-effectiveness rests on the assumption that individuals will have the capacity to pay for essential drugs and that they will make rational choices. ... Short-term savings in the drug budget may be offset by downstream costs in the treatment of potentially preventable illnesses.”

Thomson said the issue of health inequality is a tough nut to crack, one which “isn’t even on the agenda” in any practical way.

“Public health people worry about it and they write papers. But in the day-to-day lives of the health care world, the fact that you are going to die 10 or 15 years earlier in one part of Montreal than another part of Montreal isn’t something they think has anything to do with them,” Thomson said.

“Even with free access, if you want outcomes that are better for poor people, you need to put resources in a heavier and more concentrated way in those communities.”

Earlier this month, the OECD added its voice to those who have been pushing Canada to relax health care rules to allow patients to pay for core services in an effort to contain costs and trim waiting times.

Hugh Scott, a physician and former executive director of the McGill University Health Centre, takes issue with doomsayers who argue privatization is inevitable as rising health care costs put the squeeze on budgets for education, roadwork and other essential services.

He points out that the fastest growing portions of the health care budget are drugs and medical research, with doctors’ salaries and hospitals consuming an ever-smaller portion of public funds.

Rather than throwing in the towel on public health care, Scott calls for constant innovation and close, persistent scrutiny of the entire health care system to identify shortcomings and fix them. One area of particular concern for Scott, who managed the MUHC at a time when Quebec hospitals were struggling to recover from the budget-crunching of the early 1990s, has been the largely-unchecked growth of public health and administrative boards.

“There is a lot of room for improvement in the managerial skill of the people who actually manage health care systems,” said Verter, who wants to take much of the guesswork out of the decision-making in health care institutions.

“You can increase the number of beds, you can increase the number of nurses, you can increase the number of physicians. Which one should you do? You can’t do them all because you don’t have enough money.

“The problem is that usually our intuitions are wrong. … And I can assure you that the head nurse is telling something to the chief and the attending physician is saying something else,” Verter said.

“I don’t think anyone seriously thinks that the (regional health councils) are in control of the hospitals,” said Thomson. “They have no way of managing the doctors in the hospitals. All they can do to control costs is to take away some money and then the hospitals close beds and all hell breaks loose.”

That’s despite reams of documents and layers of red tape that prevent hospitals from buying a bed or a piece of machinery without the agency’s approval. “The numbers which are available from the regional health agency don’t make sense in any practical way.”

Thomson said the first big hole in our health system is the lack of information.

“Ask any manager. What gets measured get managed And we don’t have any information to manage,” she said. “Two, there is no management of demand.

“That’s why whenever anything new is needed here in Quebec, all we can do is add on extra funds. Give more money, because we don’t have any way of shifting it from one thing to another.”

To really run a public market like the health care system effectively, “you need to know how much it is costing you. And we have no idea,” Thomson said.

“We know what a hospital spent and we know what all the hospitals together spent. We know what the establishments cost. But that’s all we know.”

Under the current structure, she said, there’s no incentive for hospitals to operate more efficiently. “The more people who show up at the ER, the more work you have. The hospital is funded as an institution, not by activity. Doctors get to ‘chik-chik,’ but the hospital doesn’t.”

Nor, says Strumpf, is there a reliable way to measure cost-effectiveness of medical services delivered when physicians are paid by the visit. “When the doctor says, ‘I want to see you again in two weeks,’ it’s difficult to know whether there is a real medical need to see you again or whether its because he or she will receive a payment for that service.”

So what’s the answer?

How do we get a grip on whether we need more money when we don’t know whether the money we already have is being spent wisely?

CIHI’s Lemay said concern is brewing over the cost of drugs, which have climbed from 10 to 17 per cent of total costs since 1985. He said it’s also the only real area where he believes Quebec has room to manoeuvre. Ontario has recently moved toward capping the price of generic drugs and other provinces have been watching what happens there with keen interest.

Lemay said Quebec wouldn’t dare do anything to cramp doctors’ fees, particularly since they are already the lowest in the country and Quebec is already hard-pressed to find enough GPs to go around.

Indeed, Verter suggests getting a handle on the family doctor shortage could go a long way toward mending what ails us, and the health care budget.

“There is a sizable chunk of people who end up in the emergency department because they do not have access to a sufficient number of family physicians. So their condition worsens.

“You can’t see a family physician, your situation worsens, you go to emergency, they do something, they discharge you, and a couple of weeks later you have to go back to emergency,” Verter said, citing research showing a link between repeat visits to the ER by stroke patients and the likelihood of death in the short term.

“Almost everybody who goes to ER actually needs something. That’s why they are there. ... Well, you can certainly affect the arrival process by charging them a fee. But an alternative would be to give them some other place to go and that, to be precise, would be a family physician.”

Thomson thinks it would be useful to identify and track an episode of health care, from the time the patient showed up at the doctor’s office with symptoms to the time they were well on the way to recovery.

“You’d want to know what that cost in different places in Quebec and different institutions so you can begin to see where costs were highest in that episode of care, how they could be reduced, and if there were lots of returns (to hospital).”

Having that kind of cost breakdown is crucial, perhaps more so when there is competition from private consortiums. “If you are going to buy a television set, you need to know what a television set costs. … And we don’t have that kind of information on our health care system in Quebec.”

Thomson said she is not suggesting anyone is “twiddling their thumbs or doing their nails. … I think they are working their socks off and they are anxious and they are worried. I think they are trying their best. But I don’t think they have the kind of information they need to make a decision.”

As someone who had a front-row seat as Britain’s NHS slashed waiting times and made access to family doctors a keystone of its health care policy, Thomson can’t help feeling Canada hasn’t given enough thought to such central questions as “how service demand is expressed, how supply is organized, how funding is allocated, how services are regulated.

“Until you have really thought through how that is going to work, one piece against the other, it’s really premature to start assuming that we need to spend more money.”

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